Polycystic Ovarian Syndrome
Original Editors - Amanda Tieken from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Amanda Tieken, Mudra Shah, Lucinda hampton, Admin, Kim Jackson, Jai Taylor, Aminat Abolade, Safiya Naz, Priyanka Chugh, Kirenga Bamurange Liliane, Rishika Babburu, Tony Varela, 127.0.0.1, Elaine Lonnemann, WikiSysop, Allyson Prieto, Demiana Farag, Macy Purifoy, Wendy Walker and Evan Thomas
Definition/Description[edit | edit source]
Polycystic Ovarian Syndrome (PCOS), formerly known as Stien-Leventhal Syndrome, is a disorder affecting the hormones of women of child bearing age. Ovaries are enlarged secondary to multiple cyst formations within the ovaries.
PCOS has also been associated with features of metabolic syndrome which include insulin resistance and diabetes mellitus as well as cardiovascular factors such as dyslipidemia. Causative factors seem to be unknown but there are certain predispositions which are strongly correlated with the incidence of PCOS. Insulin resistance and compensatory hyperinsulinemia are said to be significant causes for hyperandrogenism in women with PCOS. Furthermore, obesity worsens these hormonal imbalances thus making the clinical features evident - it has been observed that women with PCOS who are obese have a higher incidence of menstrual irregularities and hirsutism compared to non obese women with PCOS[1].
Prevalence[edit | edit source]
PCOS affects 4-12% of childbearing aged women[2] It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age. [3]
- 50% of these women have amenorrhea[4]
- 30% of these women have abnormal menstrual bleeding[4]
- 60% of these women are obese[5]
- 40% of women with PCOS have associated insulin resistance and type 2 diabetes mellitus[4]
Pathophysiology[edit | edit source]
PCOS is believed to be a genetically inherited metabolic and gynecological disorder. A repetitive vicious cycle occurs with hormones resulting in the progression of PCOS. To begin with, failure of an ovary to release an oocyte results in increased levels of androgen production/release from the ovaries as well as the adrenal cortex. Excess androgens have a twofold effect. First, androgens are stored in adipose tissue where they are then converted into estrogen. Excess androgens then result in an increased production of Sex Hormone Binding Globulin (SHGB). This increased SHGB then has the consequence of an even greater fabrication of androgens and estrogens. Thus the cycle begins. The cause of the excess androgen production has been correlated to surplus Luteinizing hormone (LH) stimulation resulting in the presence of cystic changes in the ovaries.[6]
Characteristics/Clinical Presentation[edit | edit source]
Signs and symptoms of PCOS include the following:
- Enlarged polycystic ovaries[6]
- Obesity and central fat distribution[6]
- Hirsutism - male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs [6]
- Virilization - development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass, and clitoromegaly[6]
- Anovulation - failure of the ovaries to release an oocyte[6]
- Amenorrhea - absence of a menstrual period in women of childbearing age[6]
- Oligomenorrhea - presence of menstrual cycles greater than 35 days apart[6]
- Dysfunctional uterine bleeding[7]
- Acne related to hyperandrogenism[8]
- Infertility; recurrent first trimester miscarriages[2]
- Obstructive Sleep Apnea
Associated Co-morbidities[edit | edit source]
- Type 2 Diabetes Mellitus[5]
- Obesity[5]
- Cardiovascular disease[5]
- Hypertension[5]
- Ovarian cancer[5]
- Breast cancer[5]
- Endometrial cancer[5]
Diagnosis[edit | edit source]
There is no one definitive test for the diagnosis of PCOS, but rather a ruling out of other possible disorders.
- Ultrasounography - abdominal or transvaginal[4] [9]
- Pelvic Examination[4]
- Laparoscopy[4] [9]
- Laboratory testing including CBC and CA-125[4]
- Screenings for glucose intolerance[4]
Medical Management (current best evidence)[edit | edit source]
Medical management is completed through medications as previously described or surgical removal of the ovarian cysts/hysterectomy. Medications can be used to shrink ovarian cysts through control of the mentrual cycle and subsiding release of excess luteinizing hormone preventing of overproduction of testosterone.[2]
Cystectomy
Medications
Treatment for infertility may include the following for inducing ovulation:
- Clomiphene citrate[6]
- Corticosteroids[6]
- Metaformin increases spontaneous ovulation for women with insulin resistance/increased insulin production[6]
Treatment for those not interested in conceiving a child may include:
- Depo-Provera injections to decrease endometrial hyperplasia[6]
- Oral progestin[8]
- Oral combination contraceptive containing estrogen and progestin[8]
Physical Therapy Management (current best evidence)[edit | edit source]
Physical therapists should be aware of the clinical presentation of PCOS. Women with PCOS may experience low back pain, sacral pain, and lower quadrant abdominal pain. However, a thorough patient history can provide information of a gynecologic/metabolic connection. Concern of possible presence of PCOS requires immediate referral to a physician.[4]
In treating patients with a PMH of PCOS for a non-related condition, be aware of related medical concerns that may affect the patient's ability to participate in activities including glucose intolerance and insulin resistance.[4]
Side effects of medications need to also be taken into account. For example, the side effects of clomiphene citrate, an ovulation inducer, includes insomnia, nausea/vomiting, blurry vision, and frequent urination.[4]
Lifestyle Changes[edit | edit source]
Recommendations:
- Weight loss because of storage of estrogen in adipose tissue[8]
- Regular exercise (30min/day) lowering insulin levels[8]
- Reduction of carbohydrates consumed to reduce insulin levels[8]
Differential Diagnosis[edit | edit source]
- Pregnancy[2]
- Hypothyroidism[2]
- Hyperprolactinemia[2]
- Late-onset Congenital Adrenal Hyperplasia[2]
- Ovarian Tumor[2]
- Hyperthecosis[2]
- Adrenal tumor[2]
- Cushing's Syndrome [2]
Resources[edit | edit source]
Case Report: Polycystic Ovarian Syndrome: Diagnosis and Management
Case Review: Long term health consequences of polycystic ovarian syndrome
PCOS Psychosocial Well-Being, and Sexual Satisfaction in Women with Polycystic Ovary Syndrome
Health related Quality of Life in PCOS
Commentary: Promising clinical practices of metformin in women with PCOS and
early-stage endometrial cancer
References[edit | edit source]
- ↑ Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based review. Saudi Journal of Sports Medicine. 2017 Sep 1;17(3):123.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Sheehan MT. Polycystic ovarian syndrome: diagnosis & management. Clinical Medicine & Research 2004;2:13-27.
- ↑ Harrison CL, Lombard CB, Moran LJ, Teede HJ. Exercise therapy in polycystic ovary syndrome: a systematic review. Human Reproduction Update. 2010 Sep 10;17(2):171-83.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Goodman CC, Fuller KS, editors. Pathology: implications for the physical therapist. 3rd ed. St Louis: Saunders Elsevier, 2009.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Daniilidis A, Dina K. Long term health consequesnces of polycystic ovarian syndrome: a review analysis. Hippokratia 2009; 13:90-92.
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 Callahan TL, Caughey AB, editors. Blueprints: obstetrics & gynecology. 5th ed. Baltimore: Lippincott Williams & Wilkins, 2009.
- ↑ Futterweit W, Diamanti-Kandarakis E, Azziz R. Clinical features of the polycystic ovary syndrome. InAndrogen Excess Disorders in Women 2006 (pp. 155-167). Humana Press.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Merck manual of medical information. 2nd ed. New York: Merck & Co., Inc, 2003. p 1234-35.
- ↑ 9.0 9.1 Polycystic Ovarian Syndrome, PCOS and Infertility and Pregancy: What is PCOS Syndrome? Advanced Fertility Center of Chicago; Gurnee, IL. 1996-2010; 04-2010. Available from: (http://www.advancedfertility.com/pcos.htm)
